Daily genital cares of female gynecologists : a descriptive study

INTRODUCTION: Genital hygiene can play an essential role in avoiding vulvovaginal discomfort and preventing infections. The scientific evidence on best practices on genital hygiene is scarce, and without doubt, gynecologists should be the best person to discuss and guide the subject. OBJECTIVE: Evaluate the general genital female gynecologist hygiene. METHODS: This descriptive analytic study identified genital hygiene and sexual practices of 220 female gynecologists, through a questionnaire with 60 self-answered questions. The data were analyzed and presented using frequency, percentage, mean and standard deviation. RESULTS: The studied population was constituted by middle age (37.3 years) and white (71.3%) female gynecologists. More than a half (53.6%) declared spending over 10 hours a day away from home and complained of vaginal discharge in 48.1% of the cases. Regular vulvovaginal hygiene: 17.8% reported washing genitals once a day and 52% twice a day. The use of dry paper alone was reported in 66.4% post urination and 78.5% post-evacuation. Using running water and soap was practiced by 25.9% and 21.5% respectively. Vulvovaginal hygiene related to sex: More than half of them had intercourse 1-3 times a week, and 37.4% and 24.1% had frequent oral sex and eventually anal sexof the participants, respectively. Genital hygiene before sex was positive in 52.7% of the subjects and, postsex hygiene in 78.5% of them. Conclusion: Genital hygiene habits of female gynecologists can be improved, despite the high grade of scientific knowledge they hold.


INTRODUCTION
The modern woman has changed her lifestyle and social behavior, aningd her genital care changed too 1 .According to the Brazilian Institute of Geography and Statistics (IBGE), 49.5% of them work 40 to 44 hours weekly 2 .This new lifestyle imposes situations that may interfere in the vaginal ecosystem, providing or even preventing infections.The use of toilet tissue, soaps with different pH, intimate deodorants, sanitary pads, panty liners, the frequency of sexual intercourse, use of adornments, hair removal, clothing, and physical activity are important factors that should be taken into consideration, but haven't been thoroughly investigated 1 .
The anatomy of the female genitalia presents nu-merous skin creases, hair and is located in a region that hinders the aeration and increases the friction, making it difficult to remove debris 3 .There is, in this area, sweat and sebaceous glands that cause organic waste, facilitating infection or modifications, promoting odor, vaginal discharge, and vulvar pruritus.Others external factors as ingestion of drugs, sexual activity, and genital hygiene can also affect the genital well-being 1 .Genital hygiene is the set of actions aimed at removing excess residues (dead cells, secretions, oiliness, menstrual blood, lubricants, sperm, and remains of urine, feces, and paper) in the female genital area in order to promote wellness and comfort, besides preventing genital infections 1 .Genital hygiene includes, besides the local cleaning, removal of pubic hair, piercings and tattoos, use of sanitary pads and wearing appropriate clothing.
The ideal feminine genital hygiene has not been established yet and can vary in different countries.Unfortunately, the side effects of unappropriated hygiene and its consequences are not reported regularly.It is known, that total hair removal is linked to a younger age with active sexual life 4 .Sexual activity is an important factor in changing the vaginal environment, either by the presence of semen (due to the alkalinity) or introducing new bacteria or promoting micro fissures 5 .
Furthermore, feminine hygiene products such as soaps, lotions, wipes, and sanitary pads are used by women around the world daily without knowledge of its implications 6, 7 .
Pediatricians, infectious disease doctors, and dentists have already realized the importance of disease prevention practices by promoting hygiene measures and changes in lifestyle habits.Research shows that washing hands with soap reduces by 44% the morbidity from diarrhea and decreases the transmission of various infectious agents, such as the H1N1 virus 8, 9 .
Gynecologists, due to their professional knowledge, are the professionals who should know better how to guide patients on genital hygiene practices.However, few scientific publications have endorsed the guidelines which are usually presented.In practice, these professionals guide their patients without knowing the real consequences of poor hygiene, based only on common sense.
This research aimed to study the habits of hygiene in female gynecologists (products and approaches for genital hygiene, clothing habits, menstrual products, hair removal, sexual practices), since female gynecolo-gists are excellent representatives of the modern woman, with the addition of having scientific knowledge about vulvar and vaginal conditions.Thus, they should know what is better or not regarding the proper care of female genitals.Therefore, we should know how the female gynecologists take care of their own genitals as they will be health providers for other women.Gynecologists are responsible for guiding other women in their daily care and must be qualified to do so.

METHODS
This is a descriptive, analytical study that enrolled 220 female gynecologists interviewed at scientific meetings of the specialty.The research involved a self-administered questionnaire with 60 questions related to the topic: genital hygiene habits, including cleaning (frequency, time, the specific type of soap, use of wipes), hair removal, usual clothing, and use of sanitary pads or panty liners.The questionnaire was designed by the researchers themselves and is currently undergoing validation.Inclusion criteria: to be a gynecologist, complete the TCLE, and answer more than 75% of the questions.Exclusion criteria: be under antibiotics treatment in the last 15 days, be pregnant, a chronic and/or degenerative patient (cancer, diabetes, immunosuppression), be a syphilis, HIV or hepatitis patient.Some female gynecologists were approached during a specialized congress, between June and September 2013, during the coffee break.To ensure confidentiality and anonymity of the interviewees, the questionnaire was inserted by the participant in a sealed box.
During the approach, there was an acceptance rate of 84.6%.The main reason for denial was the lack of time to answer the questionnaires.After collecting the data, we developed the database in Microsoft Excel 2007.The results were analyzed using descriptive statistics, such as frequency, percentage, mean and standard deviation, where applicable.
All participants signed an informed consent form before filling out the questionnaire.The study was approved by the Research Ethics Committee of a university hospital in São Paulo, Brazil.

RESULTS
The average age of interviewees was 37.3 years (±12.9);71.4% of them were white, and 46, 8% had been a graduate for between one and ten yearsgraduated.More than half (53.6%) of the women are away from home for more than 10 hours a day.Table 1 shows that more than half (55.9%) take two baths per day, 52% wash genitals twice a day, 66.4% of them do not wash genitals after urination, using toilet paper to dry the vulvar area.Only 21.5% wash the anal area after evacuations with soap and water, and 48.6% of them frequently use intimate deodorants.The genital hygiene with liquid soap is made by only 39%, and antibacterial soaps were used by 6.8% of the interviewees; 52.7% and 78.5% sanitize them before and after intercourse respectively.Vaginal douching was reported by 21.4% of the female gynecologists.Table 2 shows that panty liners are used by 41% of them, changing it four to five times a day (34.1%).Pruritus was referred by 83.2% of the panty liners users.Over 83% shave, at least once a month, meanwhile, 31.6%twice or more.After shaving, 48.6% do not use moisturizing products to prevent complications in the region.Table 3 shows that over 85% use cotton underwear or cotton lining during the day, but only 3.63% sleep completely naked.The majority (62.7%) reported wearing tight pants.Sexual profile showed that 50.9% female gynecologists have sexual intercourse one to three times per week, 47.2% and 22.2% practiced oral and anal sex respectively.Over 29% reported pain in relations in varying intensities.

DISCUSSION
This is, perhaps, the first study on genital hygiene on gynecologists.Surprisingly, we found that even people with high scientific training could significantly improve hygiene habits and consequently, decrease not only the discomforts of the genital area but mainly prevent gynecological infections.Our attention is drawn to the fact that only 25.9% and 21.5% of the interviewees wash the genital area with running water after urination and evacuation, respectively.We know that the accumulation of residues, whether urine or feces, promote irritation and itching so that they may predispose to the formation of cracks and the increase of bacteria.Removing urine or feces using only toilet paper requires the use of strength and can scrape a region that is delicate and at the same time has many folds of skin.Gynecologists, from a practical point of view, are very similar to any other category of professionals who have to work many hours a day without adequate time and availability to do proper genital hygiene.The data collected annually by the Federal Council of Medicine provides an overview on distribution, compensation and working hours of Brazilian medical professionals, however, are lacking information about the quality of this medical health 10 .Despite their medical profile, gynecologists are similar to other Brazilian women with a hectic routine, with many working hours and unhealthy habits (smoking and physical inactivity), adding to this the constant stress of the complex universe in which they live 10 .
Hygiene practices are effective methods and recommended in various specialties to prevent diseases.Take the case of H Pylori; research currently proposes that if there was any transmission in childhood, it could be interrupted if new hygiene habits such as washing hands, not sharing oral-oral food or utensils are initiated 11 .Another example, much more palpable and well-studied in the literature, is the control of caries by proper hygiene of the teeth and oral cavity.It is known that in countries where the rate of caries is smaller there is an investment in guidance and education of dental hygiene. 12.
Similarly, there are some premises about female genital hygiene as a prevention method for genital infections.Amiri et al. 13 showed that pregnant women with Urinary Tract Infection presented as main char-  acteristic the habit of not washing hands after going to the bathroom and genitals after coitus.A 2011 Brazilian study found that using acidified liquid soap as an adjunct to metronidazole decreases the time between recurrences of bacterial vaginosis 14 .Among the interviewees, 52% 7 sanitize themselves before sexual intercourse, and 66.3% say just use toilet paper after micturitions, leading to prolonged accumulation of sperm, urine, and scraps of paper in contact with vulvovaginal mucosa may cause irritation and facilitating any vulvovaginitis.Approximately 50% of North American and European women use sanitary pads and 10% to 30% daily during the intermenstrual period with the idea of staying clean and dry 15 .A recent survey of Brazilian estimated using sanitary pads in 28.3% 16 .They used it for different reasons and associated improvement in self-esteem and security with their genital hygiene.Our study showed a high prevalence in the use of sanitary pads in the intermenstrual period (41%).It is double the use compared with European standards.This may be explained by the difficulty of work periods or the practicality of the product.
Only 9.5% of the doctors in this study used liquid soaps with acid pH, products that are recommended for the genital area because they have acidic pH similar to that of the skin of the vulva and because they have low detergency (do not excessively remove the fat from the skin and do not resect the genital area).On the other hand, 6.8% of them had the (inadequate) practice of using bactericidal soaps, since the genitals are colonized by bacteria that protect the vulvovaginal ecosystem.
Among those interviewed at least 62,7% wear tight jeans, considering the extended time away from home (more than 10 hours in half of the cases: 53%) the lack of habit of washing the vulva (33.7%) and anus (21.5%) after urination and evacuation inevitably worsens local conditions.Although 83.18% of gynecologists declared wearing cotton underwear, 62.7% of them wear tight jeans but do not have vaginal discharge.
Most of the subjects shave at least once a month (42.7%), while others (31.6%) shave two or more times a month.This implies 74.3% concerned with this process of hygiene.Twenty percent of them declare that they do vaginal douches at varying frequencies, although they are gynecologists and know that this practice is condemned by most studies, due to association with Pelvic Inflammatory Disease, bacterial vaginosis 17 .The sexual profile of interviewees is very similar to the profile of the general population.More than half reported to having sex 1-3 a week with a high prevalence of dyspareunia of 29% 18 .The discomfort to talk about sexuality was evident by the number of lost cases in issues related to sexual activities (13 lost cases).
There is a massive number of hygiene products currently available for women.The need, erroneously propagated to feel fresh, leads many women to live a dilemma between using or not using such products

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. The reality is that women, regardless of the profession, are making increasing use of hygiene products in search of vulvar health.
Because of the vocational training and science they have, the interviewed gynecologists should know the ideal way to carry out genital hygiene; however, they practice hygiene inappropriately.A survey of 341 university students (biological area, social area, and exact area) of a large Brazilian university shows patterns of genital hygiene and sexual practices very similar to those found in medical gynecologists.In this study, it was found that after sex, 69.3% of women bathe and 14.2% do not bathe but do genital hygiene, and 13.9% do vaginal douching 20 .
This study is the first to methodologically investigate the group of medical gynecologists on the subject, extending the line of research in women's clinical care.However, being a descriptive study, we believe that further research and clinical trials need to be conducted to evaluate the effects of the practice of female genital hygiene and thus offer subsidies for proper orientation on how to promote genital hygiene.

CONCLUSION
Female genital hygiene is a vital topic which should be more widespread between gynecologists and society.Gynecologists behave, regarding genital hygiene, like most women with an intense professional and social life, committing the same inadequacies as most women.Surprisingly, despite female gynecologists having previous knowledge about the vaginal environment and how to perform proper genital hygiene, some of their hygiene habits are questionable.More studies (clinical trials) need to be performed in order to provide directions to proper female genital hygiene, as well as guidelines and education for the gynecologists, collaborating with women health.

TABLE 1 .
GENITAL HYGIENE HABITS CHARACTERISTICS OF FEMALE GYNECOLOGISTS

TABLE 3 .
CLOTHING AND SEXUAL HABITS OF FEMALE GYNECOLOGISTS

TABLE 2 .
PANTY LINERS AND HAIR REMOVAL PRACTICES OF FEMALE GYNECOLOGISTS